A Budding Emergencist
Sunday, September 24, 2006
  Physician Assistants
In response to some emails and some posts regarding my overbroad criticism of neuro PA's, I wrote the following email:

I appreciate the time you took to send a note-- As well, I am grateful you took the time to read my post.

I hope you will understand my consternation at the situation I was in. Here I was, watching as the fabric of medicine fell apart. I am not entirely sure (I didn't bring it up with that particular PA) but I think a goof was made. Whether it was made by the ER doc, the neurosurgeon, anaesthesia (who I point the biggest finger at, since that was the rotation I was in--anaesthesia is meant (from my understanding) to be a kind of "medical" check to surgery's go-go-cut mentality--i.e. gee the patient should have adequate attention paid to his coagulation status before surgery.), or the neurosurgery PA, the patient is the one who suffered. In defense of anaesthesia, the case was done "emergently," meaning rapid sequence intubation, and then please STFU, anaesthesia.

My understanding of the position of the PA in this is full of holes. I do not know how much responsibility they have. I know that my father employs NPs to great effect as "physician extenders"--i.e. they are equipped to make medical decisions and act basically at the level of a mid-level resident. Is this wrong? I know that my hospital employs many PAs in the ED for nonacute cases, SIGNIFICANTLY (via "fasttrack" etc.) improving the situation for both ER docs and patients. My dad loves his NPs because he doesn't have to worry that's they're doing some crazy shit and not telling him, like some doctors that he's previously employed (and subsequently fired). NPs (and by extension PAs) are the perfect solution to this problem of the doctor (in my fathers' case, an oncologist in a rural area) not being physically able to see all the patients. Given enough information from a trusted source, management can be effected, often with brilliant results, by a physician extender, in the same way that a decent resident (i.e. me) can enable a primary care doc to see maybe not twice as many patients, but maybe 1.5 times as many. Bullshit like documentation can be comfortably delegated to an experienced practitioner. At LAC+USC, where I bowed before the gods of EM, PAs who had been there 20+ years taught the residents casting, splinting, and suturing. Again, brilliant.

HOWEVER. In this case, and with this particular PA, I feel he overstepped his bounds, failing to adequately ensure coagulation balance before the first surgery, which would have prevented the second surgery. Of course, if the first surgery was also emergent, then this whole episode falls under the category of "the patient had a complication because the patient was sick." This is partly the fault of the neurosurgeon. This particular PA has also berated and abused my senior attending anesthesiologist (with 20+ years experience in neuroanesthesia) for some bullshit I don't even give the credit of memory for. (extreme chutzpah). This mirrors the attitude of another neuro PA in a different hospital abusing medical students (namely me). So you'll forgive me if I've got a sore spot when it comes to neuro PAs. I've had very favorable encounters with PA's in other disciplines. I value the role that PAs play as long as they don't aggrandize themselves above other doctors they work with, to the extent of unprofessional behavior. It just stands out more---that which may be forgiven in an attending is certainly not excused in a PA--which illustrates the difficult nature of the job.

I have generally quite positive impressions of PAs and other "midlevel" practitioners, Dr. Crippen (NHS Blog) and his quacktitioner crusade notwithstanding. Midwives fill an absolutely critical role in my neighborhood, where I can count the number of OB-GYN's on both hands for a population of millions.

so, my hat's off to you, and sorry if I offended,


Dex, the emergencist.

So, to all you PAs, please accept this olive branch.

I would just like to add that I did not start any fires at the time, either during the case or in the patient record. In the anonymity of this blog, however, I'll say what I think.
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Emergency medicine, from the beginning of a new doctor's career.

Location: Big City, Metropolis, United States

Walk softly and carry a big vocabulary. Don't be inhuman. Find and greet God in every person you meet. The patient is the one with the disease. Do not get distracted. Charity begins at home. Do good and be happy. Don't just do something, stand still. Wear sunscreen. Don't get anyone pregnant, and don't go to jail, young man. Budget your luxuries first. You don't know what you don't know. People like learning, they just don't like being taught. When in doubt, go out. When life gives you lemons, make lemonade. Honey attracts more flies than vinegar.

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